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THE,   5HATTUCK  LLCTURL 


An  Anatomic  and  Mechanistic 
Conception  of  Disease 


BY 


JOEL  E.  GOLDTHWAIT,  M.  D. 

BOSTON 


REPRINTED    PROM 

THE  BOSTON  MEDICAL  AND  SURGICAL  JOURNAL 

JUNE  SEVENTEEN 

1915 


t  • . . «    »  . 


* , » » • « 

•  • 

■«  c 

c  c 


/ 

[Reprinted   from  the  Boston  Medical  and  Suroicai,  Jotrxal, 
Vol.   clxxii,  No.   2t,   pp.  881-898,  June  17,  1915.] 


AN  ANATOMIC  AND  MECHANISTIC 
CONCEPTION  OF  DISEASE.* 

By  Joel  E.  Goldthwait,  M.D.,  Boston. 


The  subject  which  ha.s  been  announced  for 
this,  the  twenty-sixth  lecture  given  under  the 
conditions  of  the  bequest  made  by  Dr.  Shattuck, 
was  chosen  after  much  consideration  as  being  of 
broad  general  interest  and  as  having  to  do  with 
the  fundamentals  of  medical  knowledge.  It 
seemed  possible  that  such  a  consideration  might 
be  of  sufficient  importance  to  be  worthy  of  the 
occasion,  and  if  it  be  so  considered  it  will  be  a 
satisfaction  to  me,  as  being  a  slight  return  for 
the  honor  which  you  have  conferred  upon  me  in 
selecting  me  as  your  speaker. 

The  basis  of  that  wliich  is  here  presented  is 
M^ork  which  has  been  carried  on  for  a  number  of 
years  in  the  attempt  to  find  the  cause  of  the 
chronic  disease  conditions  for  which  the  ortho- 
pedist is  consulted.  A  fairly  exhaustive  patho- 
logic investigation  failing  to  show  more  than  the 
nature  of  the  lesion,  with  similar  experience 
from  the  bacteriologic  and  the  biochemical  in- 
vestigations, led  to  the  study  of  the  fundamental 
anatomic  conditions  existing  in  patients  afflicted 
with  these  diseases,  with  results  which  have  been 
increasingly  more  suggestive  the  farther  the 
study  has  been  carried. 

*  Delivered  before   The  Massachusetts   Medical   Society   at  Boston, 
June  8,  1915. 

1 


.*/. :  :.*•  :'.'••••••• 


It  is  this  study  which  represents  the  first  part 
of  this  paper  and  which  has  been  reported  in 
part  from  time  to  time  by  the  w^riter  in  articles 
which  have  called  attention  to  the  variations  in 
the  formation  of  the  viscera  and  skeleton,  as  well 
as  to  the  peculiarities  of  the  particular  function.^ 

In  this  investigation  it  soon  became  evident 
that  the  anatomic  formation  described  in  the 
textbooks  as  normal  to  the  human  being,  rarely 
exists  in  the  individual  having  the  common 
chronic  disease,  and  in  the  study  which  natur- 
ally followed  not  only  were  the  different  ana- 
tomic types  recognized,  but  in  the  hope  of  better 
understanding  the  variations  found,  the  struc- 
ture of  the  lower  orders  of  mammals  was  studied 
with  considerable  care. 

Recently,  with  the  assistance  of  Dr.  John 
Bryant,  not  only  have  these  anatomic  findings 
been  verified  in  connection  with  his  work,^  but 
the  literature  has  been  carefully  examined  and 
the  fact  that  most  of  the  elements  to  be  presented 
have  already  been  recorded  has  served  to  in- 
crease the  belief  that  the  observations  here  stated 
are  correct  and  that  the  appreciation  of  these 
elements  is  absolutely  essential  if  any  impres- 
sion is  to  be  made  by  our  profession  upon  the 
great  field  of  chronic  medicine  which  today  rep- 
resents such  a  reproach  to  us. 

The  fact  that  no  more  has  been  accomplished 
as  the  result  of  these  numerous  contributions  to 
medical  literature  in  the  past  is  probably  due  to 
tlie  fact  that  most  of  the  work  is  fragmentary  in 
character  and  that  it  is  only  by  piecing  together 
many  of  these  separate  contributions  that  the 
significance  of  each  with  the  great  importance  of 
the  whole  is  realized. 

It  is  the  hope,  that  in  this  communication,  the 
independent  observations  which  have  been  car- 


ried  on  by  the  speaker,  may  be  so  strengthened 
by  the  similar  findings  of  these  other  observers 
that  this  knowledge  may  be  generally  applied  to 
the  study  of  our  patients. 

In  such  an  investigation,  while  the  first  thing 
that  impresses  one  is  that  the  so-called  normal 
type  of  human  being  rarely  exists  in  the  chronic 
patient,  the  second  is  that  the  variations  from 
the  normal  group  themselves  into  two  general 
types  from  which  again  there  are  many  varia- 
tions, but  that  if  the  original  type  is  appreciated 
the  variations  from  it  are  easily  traced  and  un- 
derstood. 

In  order  to  understand  better  the  types  to 
be  described,  it  is  well  to  consider  for  a  moment 
that  which  from  the  textbooks  we  call  normal. 
Normal  Human  Type.  (Figs.  1,  2  and  3). 

There  is  very  little  variation  to  be  found  in 
the  works  of  anatomy  in  that  which  is  called  nor- 
mal. The  torso  is  of  moderate  length  and  of 
moderate  breadth.  The  thorax  is  full,  and 
moderately  rounded,  the  upper  abdomen  is 
rounded  and  in  circumference  about  the  same  as 
that  taken  just  above  the  nipple.  The  costal 
border  is  formed  in  an  angle  from  70°  to  90°. 
The  diaphragm  is  high  and  there  is  generous 
space  under  the  ribs  for  the  viscera.  All  of  the 
abdominal  viscera,  except  the  lower  portions  of 
the  colon  Math  the  sigmoid  and  part  of  the  small 
intestine,  are  above  the  umbilicus.  Around  the 
viscera  and  representing  a  definite  part  of  their 
support,  as  well  as  giving  much  protection  from 
trauma  to  the  sympathetic  nerves,  ganglia 
and  blood  vessels,  are  well-defined  masses  of  fat. 
The  lower  abdomen  is  flat,  while  the  upper  abdo- 
men is  firm  and  rounded,  there  being  no  marked 
depression  under  or  inside  the  edge  of  the  ribs. 
The  spine  shows  a  mild  curve  forward  in  the  lum- 

3 


Fig.  1. 
Tlie    normal   human   type. 


FiQ.  2. 

Xormal    human    type,    showing    the    normal    inclination    of    pelvis, 

normal  elevation  of  ribs,   normal  position  of  shoulders,   etc. 


Fig.  3. 
Normal   human   type,   showing   the   moderate   breadth   of   the  body. 


6 


bar  region,  with  the  inclination  backward  from 
the  mid-lumbar,  this  resulting  in  the  general  in- 
clination of  the  abdominal  cavity  of  30°  down- 
ward and  forward  from  the  perpendicular.  The 
pelvis,  in  the  axis  of  its  cavity,  is  inclined  down- 
ward and  backward  about  60°  from  the  perpen- 
dicular so  that  the  two  axes  form  nearly  a  right 
angle. 

Of  the  special  viscera,  the  stomach  is  of  the 
pear  shape,  and  is  placed  well  up  under  the  ribs, 
occupying  the  uppermost  part  of  the  abdominal 
cavity  upon  the  left  side.  In  this  position  the 
discharge  of  its  contents  into  the  duodenum  re- 
quires but  little  effort. 

The  small  intestine  is  about  20  feet  in  length, 
is  of  good  calibre  and  muscular  tone.  The  large 
intestine,  of  five  to  six  feet  in  length,  is  adherent 
to  the  posterior  abdominal  wall  upon  the  right 
side  until  it  reaches  the  region  of  the  liver, 
when  it  turns  forward  and  inward,  crossing  with 
a  slight  downward  sag  to  tlie  splenic  flexure  well 
up  in  the  left  side  of  the  abdomen  behind  the 
stomach,  from  which  point  it  is  again  attached 
to  the  posterior  wall  (retroperitoneal)  until  it 
reaches  the  sigmoid,  where,  after  a  few  turns,  it 
becomes  the  rectum.  The  transverse  part  of  the 
colon  is  attached  to  the  liver  upon  the  right  side 
and  to  the  stomach  in  the  center  of  the  body  and 
upon  the  left  side.  The  stomach  and  liver  are 
naturally  attached  to  the  diaphragm,  and  the 
suspensory  ligament  of  the  diaphragm  is  the 
pericardium,  especially  the  right  side,  which  is 
finally  attached  to  the  anterior  part  of  the  low 
cervical  spine. 

In  the  upper  part  of  the  abdomen  in  the  solar 
plexus  of  the  sympathetic  system,  the  ganglia 
being  so  placed  that  when  the  organs  are  in 

7 


their  proper  position  there  can  be  the  least  possi- 
ble pressure  upon  or  irritation  of  them. 

These  and  many  other  elements  are  described 
in  the  anatomy  as  normal,  and  while  this  type 
does  exist  very  commonly  among  those  who  are 
well,  nevertheless,  among  the  individuals  who 
consult  the  physician,  especially  with  chronic 
disease,  this  type  is  not  often  seen,  and  it  must 
be  hard  to  understand  the  conditions  present  in 
our  patients  unless  their  special  structural  for- 
mation is  known. 

Of  the  variations  from  the  normal  there  are 
two  well-marked  types  which  are  easy  of  recog- 
nition and  are  here  described. 

Splanchn  opt  otic  (Glennard)  ;  Congenital  Vis- 
ceroptotic  ( Goldthwait,^  Smith^)  ;  Carnivorous 
(Treves,*  Werner,^  Bryant^)  ;  Hyper-o-nto- 
morph  (Bean**)  ;  Macroscelous  (Montessori^)  ; 
''Narrow-Backed"  (Industrial).  (Figs.  4,  5,  6 
and  7). 

The  type  of  human  being  for  Avhich  the  above 
and  other  terms  have  been  used  is  essentially  dif- 
ferent from  the  so-called  normal  in  most  of  its 
characteristics.  The  whole  figure  is  lighter,  not 
only  that  there  is  less  fat,  but  the  skeleton  is 
lighter  and  more  slender  in  form.  The  skin  is 
soft  and  delicate.  The  hair  is  more  abundant  in 
the  usual  places  and  frequentlj^  shows  on  parts 
where  it  is  not  normally  seen.  The  individual 
is  usually  either  tall  and  slender  or  small  and 
delicate.  The  head  is  proportionately  large,  the 
face  and  jaws  are  narrow.  The  palatal  arch  is 
high.  The  adenoid  and  tonsillar  tissue  is  apt 
to  be  excessive.  The  ears  are  usually  large  and 
prominent,  projecting  outward  and  forward. 
The  torso  is  longer  in  proportion  than  the  so- 
called  normal  and  is  also  narrower.    (Fig.   6). 

8 


Kl(i.  4. 
The  slender  congenital  \iseeroptotic  or  carnivorous  type,  showing 
the  proportionately  greater  length  of  body,  the  increased  low  lum- 
bar curve,  forward  inclination  of  pelvis,  forward  position  of  the 
shoulder,  flat  chest,  prominent  lower  abdomen,  narrow  upper  ab- 
domen, forward  position  of  head,  etc. 
I 


9 


Fio.  5. 
Slender  type,   showing  the   same   features   as   in  Fig'.    4,   except  an 
increase    in    the    forward    inclination    of    the    pelvis    and    more 
marked  forward  position  of  the  shoulder,  and  a  more  completely 
flattened  chest. 


10 


FiO.  6. 

The  congenitally  visceroptotic  type,  showing  the  extremely 

slender  back. 


11 


Fig.  7. 

The  slender  or  congenital  visceroptotic  type  in  child,   showing  the 

same  general   characteristics  as  in  adult. 


12 


The  increased  length  is  partly  in  the  thorax, 
but  chiefly  in  the  lumbar  region.  The  ribs  are 
usually  longer  than  is  normal,  the  tenth  rib  is 
almost  always  free,  aiid  when  seen  in  the  adult, 
the  downward  inclination  of  the  lower  ribs  is 
very  marked,  they  at  times,  in  the  standing  posi- 
tion, touching  the  upper  part  of  the  ilia.  The 
spine  is  smaller  in  size  than  normal  and  the  lum- 
bar vertebrae  are  more  like  the  so-called  normal 
dorsal  vertebrae  in  shape,  the  body  being  of 
about  the  same  width  laterally  as  it  is  deep 
antero-posteriorly.      (Fig.   8).     There  are  fre- 


FlG.  8. 

Lumbar  vertebra   in  slender  tyi>e,   showing  small  body  to  the  bone, 

with  slender  laminae  and  with  flat  articular  processes. 

quently  six  vertebrae  in  the  lumbar  region  with 
the  full  number  of  sacral  vertebrae,  this  being 
one  of  the  reasons  for  the  greater  proportionate 
length  of  the  body.  The  transverse  processes  are 
small  and  short  and  the  articular  processes  are 
usually  flat   (not  crescentic).     Because  of  this 

13 


formation,  the  lumbar  spine  is  much  more  flexi- 
ble than  the  normal  type  and  it  is  this  anatomic 
type  from  which  the  fancy  dancer,  the  hurdler 
and  acrobat  are  developed. 

The  thorax  is  of  fair  size,  the  lungs  are  ap- 
parently smaller  than  normal,  and  the  smaller 
size  of  the  heart  is  easily  demonstrated  by  the 
x-ray.  The  abdominal  viscera  have  peculiarities 
in  shape  and  attachment  unlike  the  normal  hu- 
man. The  stomach  is  long  and  tubular,  instead 
of  the  normal  pear  shape.  Its  attachments  are 
less  firm,  so  that  the  possible  downward  displace- 
ment in  standing  is  much  greater  than  normal. 
The  duodenum  is  usually  attached  to  the  normal 
position,  but  this  is  not  constant.  The  small 
intestine  as  a  whole  is  much  shorter  than  normal, 
containing  from  10  to  15  feet  instead  of  the  nor- 
mal 20  feet,  the  walls  are  less  thick,  and  the  lu- 
men smaller.  According  to  Bean,**  the  length  is 
from  12  to  15  feet ;  Swaim^  from  10  feet  up ; 
Bryant^  from  10  to  15.  The  mesentery  is  longer 
than  normal,  so  that  in  standing  the  small  in- 
testine is  almost  entirely  in  the  upper  pelvis  or 
lower  abdomen.  The  large  intestine  is  shorter 
than  normal,  from  three  to  five  feet,  and  much 
more  mobile.  Almost  always  upon  the  right 
side  there  is  a  free  mesentery  so  that  this  por- 
tion may  change  its  position  easily,  and  fre- 
quently the  left  side  also  has  a  mesentery,  so 
that  in  the  upright  position  the  entire  colon  lies 
below  the  crests  of  the  ilia.  The  most  common 
condition,  however,  is  with  the  normal  retro- 
peritoneal position  upon  the  left  side  with  the 
right  side  free.  The  transverse  part  of  the  colon 
is  usually  attached  to  the  stomach,  which  means 
that  it  will  be  found  below  the  position  of  the 
stomach,  even  though  the  stomach  may  have  its 
lower  border  in  the  pelvis.    With  the  transverse 

14 


colon,  while  it  is  usually  attached  to  the  stomach, 
it  frequently  has  an  entirely  free  mesentery,  as 
is  natural  with  even  the  purely  normal  type  in 
the  early  embryologie  state.  In  this  type  the 
vermiform  appendix  is  usually  well  developed, 
while  in  the  next  type  to  be  described  the  ap- 
pendix apparently  is  much  less  developed,  which 
may  in  part  explain  the  common  occurrence  of 
appendicitis  in  the  thin,  slender  individuals. 
With  this  type  of  anatomy  there  is  very  little 
retroperitoneal  fat,  palpation  of  the  flanks  is 
easy,  the  kidneys  are  naturally  mobile,  the  liver 
is  smaller  and  is  more  loosely  attached  than  nor- 
mal. 

It  is  this  type  of  anatomy  in  which  the  sca- 
phoid type  of  scapula  (Graves^)  is  found.  The 
muscles  are  formed  of  the  long  and  slender 
fibres.  The  extremities  vary  in  lengtii  as  one 
would  suppose  in  studying  comparative  anatomy, 
the  carnivora  at  times  having  very  long  legs,  as 
the  greyhound,  or  very  short  legs,  as  the  otter, 
but  they  are  usually  longer  than  is  considered 
normal  and  both  arms  and  legs  are  relatively 
slender.  The  feet  are  slender  and  often  of  un- 
naturally high  arch.  The  hands  are  slender  but 
long,  the  fingers  being  very  slender  and  tapering. 
While  this  type  is  usually  thin,  at  times  there 
is  much  accumulation  of  fat.  If  this  is  present 
it  usually  develops  rapidly,  disappearing  at 
times  equally  rapidly,  and  the  fat  is  always  soft 
with  very  little  connective  tissue  and  suggests 
poor  health. 

Uerbivorous      (Treves,*     Werner,^     Bryant^)  ; 

"Broad    Backed"    (Industrial) ;    Meso-onto- 

niorph  (Bean*')  ;  Brachyscelous  (Montessori^). 

(Figs.  9,  10,  11  and  12). 

Upon  the  other  side  of  the  normal  human  type, 

15 


t 


Fio.  9. 
The  heavy  or  extreme  herbivorous  t.vi>e,  showing  the  large,  heavy 
build  of  the  body  throughout,  the  relatively  straight  position  of 
the  i)elvis,  the  backward  bend  occurring  in  the  upper  lumbar 
region  rather  than  in  the  low  lumbar,  showing  the  lound-shaped 
liead,  flat  ear,  broad  neck,  with  the  shoulder  well  back  on  the 
thorax. 


16 


Fig.  10. 
The  broad  backed  or  herbivorous  type,   showing  the  extremely 

broad  body.  ' 


17 


Fig.  11. 

The  broad,   heavy   type,  showing  all  the   general    characteristics   of 

Figs.    9    and    10. 


18 


Fig.  12. 
The  broad,  herbivorous  type  in  the  child,  showing  the  same  general 
characteristics  of  position  of  pelvis,  curves  of  spine,  position  of 
shoulder,  hiffh  chest,  prominent  upper  abdomen,  broad  face,  flat 
ears,  as  in  Figs.  9,  10  and  11.  Tlie  position  of  hyperextension 
at  the  dorso  lumbar  juncture  is  well  shown  in  this  figure. 


19 


and  in  marked  contrast  to  the  slender,  carnivor- 
ous type,  is  the  heavily  built,  broad  backed  type 
of  human,  in  which  so  many  of  the  characteris- 
tics are  similar  to  those  found  in  the  herbivor- 
ous creatures  that  this  term  has  been  used  for 
their  designation. 

In  this  type  the  body  is  built  upon  much 
heavier  lines  throughout.  The  skeleton  is  larger 
in  proportion  and  heavier  in  structure.  The 
muscles  are  large  with  coarse  fibres.  The  skin 
is  coarse  with  scant  growth  of  hair,  which  is  lost 
early.  There  is  an  excess  of  fat  throughout  the 
body,  but  this  is  bound  together  with  much  con- 
nective tissue  so  that  the  flesh  feels  hard  and  firm 
in  contrast  to  the  soft,  flabby  feel  such  as  is 
peculiar  to  the  slender  type.  The  head  is  round, 
the  face  is  broad,  the  jaw  is  square,  the  ears  are 
usually  placed  flat  against  the  side  of  the  head, 
and  as  a  rule  are  not  very  large.  The  neck  is 
short  and  thick,  the  shoulders  are  broad  and 
square.  The  body  as  a  whole  is  broad  and  rela- 
tively short.  The  chest  is  larger  both  in  the  later- 
al and  antero-posterior  diameters  than  the  nor- 
mal. The  diaphragm  is  high,  the  costal  border 
is  formed  in  a  broad  angle,  rarely  less  than  90° 
and  sometimes  more.  The  tenth  rib  is  usually 
attached  to  the  conjoined  cartilages  in  front  and 
the  last  t"\yo  ribs  are  relatively  short.  The  lum- 
bar region  is  short,  partly  because  of  the  fre- 
quent presence  of  only  four  lumbar  vertebrae 
and  partly  because  the  sacrum  is  set  well  down 
between  the  wings  of  the  ilia.  The  abdominal 
cavity  is  broad  and  deep.  The  stomach  is  large 
and  pear  shaped.  The  duodenum  is  attached  as 
in  the  normal.  The  small  intestine  as  a  whole  is 
much  longer  than  the  normal,  and  ranges  from 
25  to  39  feet  (Bryant^).  The  large  intestine  is 
larger  and  longer  than  normal,  from  five  to  eight 

20 


and  one-half  feet  (Swaim*),  with  the  retroperi- 
toneal attachment  of  the  ascending  and  descend- 
ing portions,  the  added  length  showing  in  the 
longer  transverse  portion  and  in  the  sigmoid. 
The  liver  is  large  but  well  up  under  the  dia- 
phragm. There  is  much  retroperitoneal  and 
general  abdominal  fat  so  that  the  kidneys  are 
well  held  in  place  and  the  sympathetic  ganglia 
are  well  protected. 

The  joints  in  this  type  are  much  less  flexible 
than  in  either  of  the  other  types,  the  individuals 
as  a  whole  being  strongly  and  heavily  built. 

The  spine  is  broad  and  heavy  throughout,  but 
in  the  lumbar  region  this  is  especially  notice- 
able. The  lateral  diameter  of  the  vertebral 
bodies  in  this  region  is  considerably  greater  than 
the  antero-posterior  (Fig.  13).  the  articular  pro- 


FlG.  13. 

Lumbar  vertebra  of  heavy  or  herbivorous  type,  showing  the  broad 

body  and   the  heavy   laminae. 

21 


cesses  are  strong  and  large  and  almost  always 
of  the  crescentic  type.  The  transverse  processes 
are  long  and  broad,  and  the  process  of  the  last 
lumbar  frequently  forms  an  articulation  (the 
lumbo  sacral  transverse  articulation)  with  the 
top  of  the  sacrum.  The  long  and  broad  trans- 
verse processes  upon  the  lumbar  spine  are  simi- 
lar to  that  which  is  found  in  the  herbivorous  ani- 
mals and  which  produces  the  lateral  rounding 
of  the  back  seen  in  all  the  hoof-footed  creatures. 
This  formation  apparently  furnishes  protection 
and  attachment  for  the  many  coils  of  intestine 
in  the  abdominal  cavity. 

Because  of  the  shape  of  the  vertebrae  and  the 
character  of  the  articulation  with  the  sacrum, 
there  is  less  lumbar  curve  forward  than  is  pres- 
ent in  either  of  the  other  types  (Figs.  1  and  2 
and  4  and  5 ) ,  and  the  forward  inclination  of  the 
pelvis  is  also  less.  The  axis  of  the  sacrum  is 
more  nearly  perpendicular.  In  this  type  not 
only  are  the  wings  of  the  ilia  higher  than  in  the 
normal  so  that  the  transverse  process  of  the  last 
lumbar  articulates  not  only  with  the  sacrum,  but 
also  at  times  with  the  ilium,  and  in  a  few  cases 
the  transverse  process  of  the  vertebrae  above 
also  rests  against  the  ilium  or  has  strong  liga- 
mentous attachment  to  it. 

The  extremities  in  this  type  vary  in  length  as 
one  would  expect  from  the  study  of  the  compara- 
tive anatomy  of  the  herbivorous  creatures,  but 
are  always  heavy.  The  legs  are  large,  the  knees 
are  straight,  the  feet  are  broad  in  proportion  to 
length,  and  the  arch,  while  it  may  be  very  strong 
is  usually  quite  low.  The  arms  are  heavily  built, 
and  the  shoulder  attachment  is  well  back  upon 
the  thorax,  giving  the  square  shoulder  appear- 
ance. The  hands  are  broad  and  "chubby,"  both 
in  the  palmar  portion  and  in  the  fingers. 

22 


Spinal  Motions  of  the  Different  Types. 

Because  of  the  different  structure  of  the  bones 
of  the  spine,  the  motions  must  vary.  In  the  nor- 
mal, in  bending  forward  the  spine  is  well 
rounded  and  laterally  there  is  some  motion  be- 
ginning at  the  lumbo  sacral  juncture  and  extend- 
ing up  to  the  low  dorsal  region,  while  in  back- 
ward bending  considerable  motion  is  allowed.  In 
the  carnivorous  type  this  is  similar,  only  the 
amount  of  motion  is  much  greater,  as  would  be 
expected  from  the  description  of  the  bony 
formation  of  the  type.  With  the  herbivor- 
ous type,  as  must  be  apparent,  the  spinal  mo- 
tions are  much  less  free.  In  this,  the  forward 
bending  is  made  largely  at  the  hips,  there  be- 
ing but  little  in  the  spine.  Laterally  practically 
no  motion  is  allowed  except  at  the  dorso  lumbar 
juncture,  none  whatever  being  allowed  in  the 
low  back  if  the  lumbo  sacral  transverse  joint 
exists.  If  this  exists  upon  one  side,  no  motion 
at  that  region  will  be  allowed  to  that  side,  while 
to  the  other  side  slight  motion  may  be  allowed. 
In  backward  bending  very  little  is  allowed,  and 
if  the  lumbo  sacral  transverse  joint  exists,  none 
will  be  allowed  at  the  lumbo  sacral  juncture. 

Such  are  the  three  general  types  which  are  com- 
mon in  the  human  family,  and  as  to  the  fact  that 
such  tj'pes  exist,  there  can  be  no  question,  if  the 
passersby  upon  the  street  are  noticed,  even  if  one 
is  not  willing  to  accept  the  statements  of  those 
who  have  studied  anatomy  in  this  way.  The  thin 
carnivorous  person  is  there  side  by  side  with  the 
broad,  full-faced  herbivorous  person,  with  the 
normal  human  also  present,  and  the  character- 
istics are  so  distinct  that  nothing  more  than  the 
glance  is  necessary  to  recognize  the  special  form. 
The  characteristics  are  equally  apparent  in  child- 

23 


hood  as  in  adult  life,  as  is  indicated  by  the  ac- 
companying illustrations. 

The  difference  in  the  types  and  the  fitness  of 
each  for  different  forms  of  work  is  already 
known,  and  a  person  who  is  at  the  head  of  an 
organization  employing  large  numbers  of  labor- 
ers states  that  when  an  order  for  laborers  is 
given  it  is  expected  that  it  will  indicate  so  many 
"broad  backs"  or  so  many  "narrow  backs." 
The  "broad  back"  is  fitted  for  the  ordinary 
heavy  work,  while  the  "narrow  back"  is  fitted 
for  the  work  requiring  greater  agility,  such  as 
climbing  poles  or  trees,  prospecting,  running  the 
lines,  etc.  The  "broad  back"  carries  the  heavier 
load,  but  the  "narrow  back"  carries  his  lighter 
load  more  rapidly. 

The.  difference  in  the  anatomic  types  is  also 
recognized  consciously  or  unconsciously,  in  art, 
and  nothing  can  be  more  perfectly  normal  than 
the  early  (not  always  the  late)  Greek  figures,  or 
Michael  Angelo's  "David,"  or  "William  Hunt's 
"Bathers."  The  type  which  Rubens  almost  al- 
ways depicts  is  the  heavy,  full-blooded  herbivor- 
ous type,  while  the  slender,  carnivorous  type  is 
the  one  depicted  by  Botticelli  and  Fra  Angelico, 
or  by  Puvis  de  Chavannes  of  the  modem  school. 

The  fact  that  such  types  exist,  but  that  they 
also  have  different  characteristics  which  should 
be  recognized  in  their  training,  is  shown  by  Dr. 
Montessori  in  her  book,  "Pedagogical  Anthro- 
pology," in  which  the  pictures  of  the  types 
are  shown  and  the  intellectual  characteristics 
discussed. 

In  athletics  also  the  appreciation  of  the  dif- 
ferent physical  types  is  clearly  understood.  The 
hurdler  or  the  runner  is  usually  of  the  normal  or 
the  slender  type,  while  the  hammer  thrower,  the 
shot  putter  or  the  wrestler  is  usually  of  the 

24 


heavy  type.  The  heavy  men  are  usually  found 
in  the  line  of  the  football  team,  while  in  the 
backfield  the  more  slender  and  agile  persons  are 
found. 

The  types  exist,  and  in  a  very  large .  number 
of  instances  the  types  are  pure,  the  carnivorous 
being  carnivorous  throughout,  the  normal  hu- 
man being  the  normal  human  throughout,  and 
the  same  is  true  of  the  herbivorous.  In  other 
instances,  however,  the  types  are  mixed,  and  it  is 
here  that  the  greatest  difficulty  exists  in  under- 
standing the  symptoms  or  in  planning  the  treat- 
ment. A  carnivorous  type  in  general  build  and 
viscera  may  have  an  herbivorous  type  of  spine, 
a  combination  which  is  quite  common  in  women. 
A  carnivorous  type  of  stomach  and  intestine  may 
exist  with  a  normal  liver  and  kidneys,  in  so  far 
as  shape  and  position  are  concerned.  The  normal 
type  in  general  may  have  one  or  many  of  the 
characteristics  of  either  the  carnivorous  or  the 
herbivorous.  The  herbivorous  type  may  show 
characteristics  of  either  of  the  others  and  prob- 
ably the  most  common  variation  in  this  type  is 
the  smaller  spine  and  the  imperfectly  attached 
colon,  but  of  the  full  length. 

That  such  differences  exist  in  the  anatomic 
formation  of  members  of  the  human  family  there 
can  be  no  question,  and  it  is  not  unreasonable 
to  expect  such  differences  if  the  biologic  princi- 
ples of  the  development  of  the  race  are  con- 
sidered. The  human  being  as  the  highest  type 
of  mammal  naturally  inherits  something  of  the 
strains  which  have  shown  themselves  in  the  vari- 
ous species  through  which  the  advance  of  the 
mammalian  group  has  occurred,  and  it  is  only 
by  studying  comparative  anatomy  that  the  vari- 
ous differences  of  type  can  be  understood. 

From  the  purely  medical  point  of  view  the 

25 


recognition  of  these  different  types  is  important 
since  the  types  apparently  carry  their  own  po- 
tential of  disease.  The  tuberculous  and  the  in- 
fections in  general,  the  nervous  diseases  and 
acute  mental  disorders,  the  hyperglandular  dis- 
turbances, the  progressive  anemias,  the  atrophic 
arthritis,  many  of  the  intestinal  disorders,  etc., 
naturally  are  associated  with  the  slender  type. 
The  arterio-sclerosis,  hypertrophic  arthritis, 
gout,  diabetes  (not  the  insipidus),  chronic  dis- 
ease of  the  kidney,  gall  stones,  the  prostatic 
hypertrophy,  the  degenerative  mental  disorders, 
etc.,  are  common  to  the  heavy  type.  The  sug- 
gestiveness  of  this  in  treatment  must  be  obvious. 

Habits  of  Posture  in  the  Different  Types  and  the 
Effect  upon  the  Physiology. 

Not  only  has  the  study  of  the  chronic  patient 
shown  that  the  different  anatomic  types  exist, 
but  that  this  alone  can  hardly  explain  all  the 
phenomena.  The  more  the  problem  is  studied, 
the  more  evident  it  becomes  that  the  life  of  the 
creature  as  an  erect  biped  is  a  very  different 
thing  from  that  of  the  quadruped  in  so  far  as  the 
function  of  the  different  parts  is  concerned. 

One  of  the  penalties  that  the  human  being  is 
forced  to  accept  in  his  being  the  highest  type  of 
mammal,  is  that  in  locomotion,  with  the  body 
used  as  an  erect  biped,  gravity  is  constantly 
operating  to  drag  the  organs  downward  out  of 
their  normal  position,  as  well  as  to  draw  the  up- 
per part  of  the  body  downward  and  forward 
into  positions  which  must  mean  strain  and  weak- 
ness. This  element,  together  with  the  anatomic 
form,  seems  many  times  sufficient  to  cause  the 
conditions  seen  in  chronic  medicine. 

The  counteracting  element,  to  offset  such  a 
handicap  and  prevent  the  race  from  being  irre- 

26 


parably  harmed,  is  the  intelligence  with  which 
the  human  being  is  peculiarly  endowed.  The 
real  purpose  of  such  a  paper  as  this  is  to  help  in 
the  training  of  tliis  intelligence  so  that  life  may 
be  a  period  of  wholesome,  healthy  development, 
with  the  fullest  possible  energy  available  for 
whatever  stress  to  which  the  individual  may  be 
subjected. 

The  way  the  body  is  used  is  of  quite  as  much 
importance  as  the  structure  of  the  body  itself 
Either  type  has  the  potential  of  good  health  i^ 
used  rightly,  but  each  has  an  equally  definite 
potential  of  disease  if  the  proper  relationship 
between  the  many  parts  is  not  preserved.  With 
the  normal  type  it  is  naturally  easier  to  maintain 
this  relationship,  but  the  possibility  of  not  main- 
taining it  is  painfully  apparent  as  one  goes 
among  one's  fellow  men.  With  the  other  types 
the  special  postures  or  the  form  of  the  malad- 
justment naturally  differs  as  one  would  expect 
from  the  structure. 

Since  the  pathologic  changes  which  are  seen 
are  apparently  due  very  largely  to  this  imper- 
fect adjustment  of  the  parts,  it  is  of  the  first  im- 
portance that  the  postures  or  special  elements 
of  maladjustment  which  are  peculiar  to  the  dif- 
ferent types  should  be  appreciated.  It  should 
also  be  remembered  that  with  the  chronic  pa- 
tient the  large  majority  of  the  cases  fall  into  the 
slender,  congenital  visceroptotic  type  or  the 
broad,  herbivorous  type. 

The  Normal  Human. 

When  the  body  is  used  rightly  (Fig.  1  or  2), 
all  of  the  structures  are  in  such  adjustment  that 
there  is  no  particular  strain  on  any  part.  The 
physical  powers  are  at  their  best,  the  mental 
functions  are  performed   most  easily,  and   the 

27 


personality  or  spirit  of  the  individual  possesses 
its  greatest  strength. 

When  used  rightly,  or  fully  erect,  the  feet, 
knees,  hips,  spine,  shoulders,  head  and  all  the 
portions  which  represent  the  frame  of  the  body, 
are  used  in  balance,  with  the  greatest  range  of 
movement  possible  without  strain.  In  this  po- 
sition the  chest  is  held  high  and  well  expanded, 
the  diaphragm  is  raised,  and  the  breathing  and 
heart  action  are  performed  most  easily.  The  ab- 
dominal wall  is  firm  and  flat,  and  the  shape  of 
the  abdominal  cavity  resembles  an  inverted  pear 
(Forbes,  Williams^®')  (Fig.  14),  large  and  round- 
ed above  and  small  below.  The  ribs  have  only  a 
moderate  downward  inclination.  The  subdia- 
phragmatic space  is  ample  to  accommodate  the 
viscera.  In  this  position,  also,  there  is  no  undue 
pressure  upon,  or  interference  with,  the  pelvic 
viscera  or  with  the  large  ganglia  at  the  back  of 
the  abdomen  and  in  the  pelvis. 

Relaxed  Position. 

If  the  body  is  drooped  or  relaxed,  so  that  the 
shoulders  drag  forward  and  downward,  the 
whole  body  suffers,  the  weight  is  thrown  imper- 
fectly upon  the  feet,  so  that  the  arch  must  be 
strained ;  the  knees  are  slightly  sprung,  which 
shows  by  the  crepitating  joints;  the  pelvis  is 
changed  in  its  inclination,  with  strain  to  the 
sacro-iliac  joints  and  low  back.  The  increased 
forward  curve  of  the  upper  dorsal  spine  results 
not  only  in  strain  to  the  intraspinous  ligaments, 
but  also  forces  the  shoulders  forward,  with  fre- 
quent irritation  of  the  bursae  about  the  shoul- 
ders, or  compression  of  the  brachial  plexus,  with 
pain  and  neuralgias  in  the  arms,  while  the  cran- 
ing forward  of  the  head  must  result  in  strain  to 
the  posterior  part  of  the  cervical  spine. 

28 


Fig.   14.     (Williams.) 


29 


/ 


In  this  position  the  chest  is  necessarily  low- 
ered, the  lungs  are  much  less  fully  expanded 
than  normal,  the  diaphragm  is  depressed,  the  ab- 
dominal wall  is  relaxed,  so  that  with  the  lessened 
support  of  the  abdominal  wall,  together  with  the 
lowering  of  the  diaphragm,  the  abdominal  or- 
gans are  necessarily  forced  downward  and  for- 
ward. When  this  occurs  the  possibility  of  me- 
chanical interference  with  the  function  of  the 
organs  is  not  difficult  to  imagine,  and  it  becomes 
apparently  a  mere  matter  of  chance  which  organ 
is  affected. 

The  thing  that  is  important  in  the  interpreta- 
tion of  the  many  symptoms  which  the  patients 
describe  is  that  the  body  is  most  intimately  re- 
lated in  its  different  parts  so  that  no  one  part 
can  be  used  wrongly  without  the  body  as  a 
whole  suffering.  For  this  reason,  if  these  vari- 
ous groups  of  symptoms  are  to  be  considered 
as  purely  local  and  distinct  lesions,  the  results 
are  sure  to  be  unsatisfactory.  The  body  as  a 
whole  should  be  considered  and  not  just  the 
chest  or  the  abdomen  or  the  feet  or  the  back  or 
any  one  part,  and  it  should  be  considered  with 
reference  to  use  in  the  different  positions  in  the 
routine  of  life,  especially  those  which  are  main- 
tained for  long  periods,  the  occupational  pos- 
tures. In  sitting  it  is  perfectly  possible  to  sit 
so  that  the  trunk  is  in  practically  the  same  shape 
and  with  the  different  parts  in  practically  the 
same  relation,  as  they  are  when  the  body  is  used 
fully  erect.  At  the  same  time  in  sitting  it  is 
very  common  to  have  the  body  markedly 
drooped,  so  that  the  body  is  rounded  forward 
with  the  lumbar  spine  entirely  reversed  in  its 
curve,  with  the  ribs  low,  so  that  the  thorax  prac- 
tically telescopes  into  the  abdominal  cavity. 
When  such  a  position  is  studied  with  reference 

30 


to  the  mechanics  of  the  function  of  the  organs 
the  wonder  is  not  that  disturbances  result,  but 
that  the  disturbances  are  not  more  marked. 

In  such  a  study  of  the  mechanics  of  the 
physiology,  the  positions  assumed  when  the  pa- 
tient is  lying  down  should  be  investigated.  It 
is  perfectly  possible  to  produce  practically  the 
same  effect  upon  the  shape  of  the  body  and  upon 
the  thoracic  and  abdominal  cavities  that  is  pres- 
ent when  the  patient  is  sitting  in  the  slouched 
position,  if  when  lying  down  several  pillows  are 
placed  under  the  head  and  shoulders,  as  is  so 
frequently  seen.  In  such  a  position  naturally 
the  breathing  and  circulation,  the  digestion,  and 
the  other  physiological  functions  cannot  go  on 
rightly,  and  the  restless,  dreaming  sleep  is  many 
times  due  to  no  other  cause  than  this. 

The  importance  of  the  proper  relationship  of 
the  parts  should  be  borne  in  mind  under  all 
conditions,  and  especially  at  the  times  of  occu- 
pation or  when  the  postures  are  assumed  for 
continuous  periods.  It  is  under  such  conditions 
that  naturally  the  greatest  harm  results,  and 
it  should  be  remembered  that  irrespective  of  the 
type,  the  postures  which  are  assumed  as  the 
body  is  used  determine  very  largely  whether 
the  individual  is  to  be  well  or  ill.  The  most 
perfect,  anatomically,  may  have  the  poorest 
health,  while  the  most  imperfect,  anatomically, 
may  have  good  health.  Fig.  15  is  of  the  normal 
type  as  is  shown  when  the  body  is  held  erect 
(Fig.  16)  but  the  posture  commonly  maintained 
(Fig.  15)  suggests  very  little  of  normal  vigor- 
ous health. 

The  postures  which  are  assumed  by  the  other 
anatomic  types  are  perfectly  characteristic,  so 
that  once  they  are  appreciated,  the  posture  it- 
self very  largely  indicates  the  type  of  anatomy 

31 


Flo.  15. 

The  normal  human  tyi>e,  with  acquired  habits  of  bad  posture,  with 

ni;irke<l   visceroptosis,  drooped  shoulder,   etc. 


32 


Flo.  16. 

The  same  case  as  Fijf.  15,  except  that  the  body  is  held  at  attention, 
showing  the  way  the  viscera  are  drawn  up  under  the  diaphragm, 
givinsr  the  normal  lines  of  the    body  when  the  body  is  held  erect. 


33 


to  be  found  in  the  individual.  It  is  always  to 
be  remembered  that  while  the  type  is  present  at 
the  time  of  birth,  that  the  extreme  characteris- 
tics which  are  seen  in  adult  life  are  largely  the 
result  of  stretch  and  strain  due  to  the  downward 
displacement  which  is  the  rule  if  the  body  de- 
velops without  guidance.  As  long  as  the  child 
remains  a  quadruped,  as  it  is  in  the  first  two 
or  three  years  of  life,  the  special  peculiarities 
are  of  very  little  concern,  but  as  soon  as  it  be- 
gins to  assume  the  erect  posture  for  long  inter- 
vals the  peculiar  postures  begin  to  show  and  the 
symptoms  which  naturally  result  therefrom  be- 
gin to  develop. 

The    Congenital    Visceroptotic    or    Carnivorous 
Type. 

In  the  slender  type,  while  the  ideal  standing 
position  is  the  same  as  with  the  normal  human, 
the  natural  position  which  will  be  assumed  is 
one  in  which  the  general  relationship  of  the 
parts  is  much  disturbed  (Figs.  4,  5  and  7).  In 
this  type  the  chest  is  flat,  the  usual  standing  po- 
sition being  with  the  chest  at  full  expiration  so 
that  all  breathing  is  done  from  the  low  point. 
The  sternum  is  more  nearly  perpendicular,  in- 
stead of  the  forward  inclination,  which  is  nor- 
mal. The  costal  border  is  inevitably  narrower 
than  in  the  normal  type,  the  angle  being  usually 
under  45,°  while  at  times  in  adult  life  it  is  so 
slight  as  to  be  hard  to  insert  the  fingers  between 
the  costal  cartilages  of  the  two  sides.  Because 
of  this  position  of  the  ribs,  the  upper  abdomen 
is  naturally  very  small  and  the  abdominal  vis- 
cera must  be  in  a  different  position  from  that 
seen  in  the  normal  type.  The  general  shape  of 
the  abdominal  cavity  resembles  the  normal  pear 
(Forbes,  Williams^"),   large  below  and  narrow 


Fig.  17.     (Williams.) 


35 


above.  (Fig.  17).  Because  of  this  the  liver  is 
displaced  downward  and  it  is  usually  rotated 
to  the  right,  so  that  the  right  border  is  fre- 
quently below  the  crest  of  the  ilium.  The  retro- 
peritoneal fat  is  practically  entirely  lacking, 
with  the  result  that  the  kidneys  are  usually  mo- 
bile, the  position  occupied  depending  entirely 
upon  the  position  assumed  by  the  individual  at 
the  time  of  examination.  Because  of  the  ab- 
sence of  the  retroperitoneal  fat,  the  sympathetic 
ganglia  and  the  large  blood  vessels  must  lie  un- 
protected upon  the  anterior  part  of  the  spine, 
and  it  is  not  improbable  that  the  changing  po- 
sitions of  the  organs,  in  the  changing  positions 
of  the  body,  must  at  times  lead  to  irritation  or 
harmful  pressure  of  these  ganglia  or  vessels. 
The  same  thing  is  probably  true  of  the  adrenals, 
which,  being  unprotected  by  fat  pads,  must  be 
pressed  upon  and  irritated  more  than  is  normal, 
this  mechanical  disturbance  possibly  explaining 
the  peculiarity  of  the  structure  of  the  adrenal 
in  this  type  of  anatomy,  which  has  been  de- 
scribed by  Dr.  Bryant. 

In  this  type  of  anatomy,  since  the  ribs  are 
lowered  in  front,  the  diaphragm  must  be  lower 
than  is  normal,  and  this  is  increased  by  the 
drag  of  the  loosely  attached  stomach,  liver  and 
colon.  Because  of  this,  the  movement  of  the 
diaphragm  in  respiration  must  be  less  than  nor- 
mal, with,  at  times,  practically  no  movement 
whatever  showing  in  the  Roentgenological  study. 
The  effect  of  this  upon  the  breathing,  as  well  as 
upon  the  circulation,  especially  in  the  large  ab- 
dominal veins,  to  say  nothing  of  the  function  of 
the  other  organs,  must  be  very  apparent. 

The  constant  position  assumed  by  this  type 
is  with  the  body  inclined  backward  from  the 
low  lumbar  region,  making  a  sharper  curve  in 

36 


the  low  spine  than  is  normal,  the  spine  above 
this  point  being  relatively  straight  to  the  upper 
dorsal  region,  from  which  point  it  bends  sharply 
forward  to  the  midcervical  region,  where  it 
bends  backward  again  to  make  the  upright  po- 
sition of  the  head  possible.  (Figs.  4  and  5). 
The  general  impression  created  by  such  a  posi- 
tion when  the  individual  is  dressed  is  often  that 
of  being  quite  erect.  In  tliis  position  with  the 
ribs  low  in  front  there  is  imperfect  support  for 
the  shoulders,  so  that  they  are  drooped  forward' 
(Figs.  4,  5  and  18),  the  scapulae  being  rotated 
outward  at  the  top,  so  that  their  long  axis  is 
much  more  oblique  than  normal.  In  this  posi- 
tion the  upper  part  of  the  scapulae  does  not 
rest  against  the  ribs,  and  since  the  position  ex- 
ists in  childhood  when  the  bones  are  soft,  the 
unsupported  upper  part  usually  is  flexed  for- 
ward, this  flexed  portion  rubbing  over  the  ribs 
when  the  shoulders  are  extended  and  gives  rise 
to  the  sensation  of  crepitation  so  commonly  felt. 
This  irritation  if  continued  naturally  causes  the 
pain  so  frequently  referred  to  this  region.  "With 
this  general  posture  there  are  two  regions  of  the 
spine,  the  low  lumbar  and  the  low  or  midcervi- 
cal, in  which  the  degree  of  hyperextension  is 
greater  than  is  normal,  and  since  in  hyperexten- 
sion the  posterior  portions  of  the  vertebrae,  must 
be  brought  closer  together  than  is  normal,  and 
since  the  foramina  through  which  the  nerve 
roots  pass  are  posterior  to  the  point  of  motion, 
it  is  obvious  that  in  this  position  the  foramina 
must  be  narrowed.  Since  this  position  is  the 
habitual  one  with  this  type  it  is  not  impossible 
that  some  of  the  little  understood  symptoms  re- 
ferred to  the  arms  and  legs  (the  parts  naturally 
supplied  with  sensation  and  motor  control  from 
these   two  hyperextended  regions)    or  some   of 

37 


Fiii.  IS. 

The  slender,  congenital  visceroptotic  or  carnivorous  type,  showing- 
the  forward  position  of  the  shoulder,  with  marked  rotation  of  the 
scapula.  In  this  position  the  head  of  the  humerus  is  lowered  and 
rotated  inward  so  that  it  rests  against  the  second  rib,  and  the 
possibilities  of  crowding  the  vessels  of  the  arm  or  the  nerves  of 
the  arm  leading  to  the  circulatory  disturbances,  neuritis,  or  neu- 
ralgias of  the  arTii,   are  evident. 


3S 


the  circulatory  disturbances  of  the  spinal  cord 
may  be  due  to  this  anatomic  position. 

With  this  hyperextension  of  the  lumbar  re- 
gion and  the  backward  inclination  of  the  upper 
body,  the  longitudinal  axis  of  the  abdomen  is 
naturally  moved  backward  at  the  top,  but  at  the 
same  time  the  pelvis  is  tipped  forward  and 
downward  (Figs.  4  and  5),  so  that  its  longitu- 
dinal axis  is  moved  forward  at  the  top  (Fig.  19) . 
The  result  of  this  is  that  the  hips  stick  out  at 
the  back  more  than   is  normal   and  the  angle 


Fio.  19. 

Spine  and  pelvis,  with  left  ilium  removed,  of  slender  or  carnivorous 
type,  showing  the  marked  forward  inclination  of  sacrum.  The 
weight  of  body  must  be  thrown  upon  the  front  of  the  sacrum,  and 
naturallv  leads  to  sacro-iliac  strain  or  displacement. 

39 


formed  by  the  intersection  of  the  two  axes,  pel- 
vis and  abdomen,  is  less  than  is  normal.  In  this 
position  the  pelvis  has  its  forward  inclination 
changed  so  that  it  at  times  is  from  30°  to  40^ 
away  from  the  so-called  normal  position.  Natur- 
ally in  this  position  the  upper  part  of  the  sac- 
rum, upon  which  the  spine  rests,  is  moved  for- 
ward and  downward  and  the  weight  of  the  body 
constantly  tends  to  increase  this  forward  posi- 
tion with  resulting  abnormal  strain  to  the  sacro- 
iliac joints.  This  being  the  case,  it  is  not  sur- 
prising that  it  is  in  this  type  of  anatomy  that 
the  strains  and  displacements  of  the  sacro-iliac 
joints  are  most  commonly  seen. 

With  this  general  peculiarity  of  poise,  the 
weight  is  naturally  thrown  upon  the  feet  wrong- 
ly, so  that  the  usual  high  arched  foot  is  marked- 
ly pronated  and  the  knees  are  sprung,  usually 
with  some  knock  knee. 

In  considering  the  mechanics  of  the  viscera, 
naturally  the  same  conditions  as  to  position  or 
mode  of  use  of  the  body  apply  as  were  indicate(i 
with  the  normal  human  type.  The  special  thing 
to  be  borne  in  mind  in  this  slender  type  is  that 
all  the  disturbances  of  poise  are  more  easily 
harmful  than  would  be  true  with  the  normaf 
human  or  the  more  stockily  built  types.  Par- 
ticularly it  is  desirable  that  the  positions  as- 
sumed at  night  should  be  considered  carefully. 
The  absence  of  the  posterior  abdominal  fat  pads 
which  fill  up  so  much  of  the  lateral  spinal  spaces 
naturally  allows  the  loosely  attached  organs  to 
drag  backward  much  more  than  is  possible  in 
the  normal  type.  This,  together  with  the  lack  of 
protection  of  the  ganglia  and  the  blood  vessels 
upon  the  front  of  the  spine  makes  mechanical 
pressure  more  easily  possible  than  occurs  in 
the  normal.     It  is  not  improbable  that  it  is  this 

40 


drag  or  pressure  upon  these  structures  during 
the  periods  of  complete  relaxation  in  sleep  that 
explains  the  common  subnormal  temperature, 
with  the  weak  pulse,  the  low  blood  pressure, 
and  the  general  lack  of  vitality  which  is  usually 
present  with  this  type  of  individual  in  the 
morning.  For  this  reason  it  is  particularly  de- 
sirable that  this  type  of  individual  should  sleep 
either  face  downward  or  upon  the  side,  so  that 
the  drag  of  the  organs  tends  to  pull  away  from 
the  spine  rather  than  to  press  backward  upon 
the  spine,  as  would  be  inevitable  if  the  back 
position  were  assumed.  The  same  possibility  of 
backward  pressure  upon  the  ganglia  or  vessels  is 
to  be  carefully  borne  in  mind  at  times  of  opera- 
tion upon  this  type,  and  the  back  position  after 
operation  be  maintained  as  little  as  possible  un- 
less there  is  some  support  planned  for  the  low 
back  and  loins. 

With  this  type  it  should  be  remembered  that 
good  poise  is  possible  (Fig.  20,  the  same  child 
as  Fig.  7),  but  that  it  requires  greater  effort  on 
the  part  of  the  individual  and  greater  patience 
on  the  part  of  the  helpers  than  would  be  re- 
quired by  the  normal. 

The  Broad-Backed,  Herhivorous  Type. 

With  this  type  of  anatomy  the  harmful  dis- 
turbances of  poise  as  a  rule  develop  much  later 
in  life  than  with  the  slender  type,  because  the 
shape  of  the  spine  and  the  general  structure  of 
the  body  withstand  strain  much  longer  than  the 
more  lightly  built  creature.  In  childhood  the 
general  posture  is  with  the  body  erect  and  in 
good  poise,  not  unlike  that  assumed  or  consid- 
ered desirable  in  the  normal  type. 

With  this  heavy  type  the  disturbances  of  pos- 

41 


Fig.  20. 
The  same  case  as  Fisy.   7,  showing  the  possibility  of  the  erect  pos- 
ture, but  showing:  the  marked  hollow  under  the  ribs  as  the  result 
of   the  low   position   of  the   viscera. 


42 


ture  come  about  chiefly  because  of  the  abnor- 
mally large  and  heavy  abdominal  viscera.  This 
leads  to  the  backward  inclination  of  the  body  as 
the  weight  of  the  abdomen  increases,  but  since 
the  formation  of  the  low  lumbar  spine,  with  this 
type,  does  not  allow  of  backward  bending,  the 
inclination  takes  place  either  from  the  hips  or 
at  the  dorso-lumbar  juncture  (Fig.  9).  The 
strain  produced  upon  the  low  back  as  the  result 
of  the  posture  may  lead  to  marked  sensitiveness 
at  the  lumbo-sacral  juncture,  due  either  to  the 
crowding  of  the  transverse  process  against  the 
top  of  the  sacrum  with  the  irritation  of  the 
bursae  which  so  commonly  lie  between,  or  to  the 
irritation  of  the  articulations  formed  by  the 
articular  processes,  or  by  the  crowding  together 
of  the  spinous  processes  with  the  pinching  of 
the  intraspinous  ligament.  Many  of  the  cases 
of  lumbago  are  undoubtedly  to  be  explained  by 
such  strain. 

In  this  type  of  anatomy  the  inclination  of  the 
pelvis  is  never  forward  more  than  is  normal, 
but  is  apt  to  be  thrown  backward  at  the  top 
since  the  pelvis  moves  with  the  low  spine,  and 
since  the  backward  inclination  usually  takes 
place  at  the  hip  joints  instead  of  in  the  lumbar 
spine.  With  such  a  backward  tendency,  if  one  of 
the  transverse  processes  is  larger  tlian  the  other, 
or  if  the  lumbo  sacral  transverse  articulation 
exists  upon  one  side,  or  is  more  marked  upon 
one  side  than  the  other,  or  if  the  articular  pro- 
cesses are  peculiar  in  shape,  so  that  one  is  cres- 
eentic  while  the  other  is  broad,  it  is  obvious  that 
with  the  backward  inclination,  the  body  is 
thrown  to  the  side,  with  at  times  a  marked 
lateral  deformity.  It  is  in  this  type  that  the  so- 
called  sciatic  scoliosis  is  so  often  seen  (Fig.  21). 
The    symptoms    which    would   naturally    result 

43 


Fig.  21. 
The  broad  backed,  herbivorous  type  with  the  lunibo  sacral  transverse 
joint  upon  the  left  side,  with  strain  and  irritation  of  this  joint, 
resulting  in  marked  list  of  the  body,  with  much  pain  in  the  left 
leg,  and  ijartial  paralysis  of  the  anterior  thigh  muscles,  the  so- 
called   sciatic  scoliosis. 


44 


from  this  would  be  pain,  not  in  the  sacro-iliac 
joints  as  in  the  other  type,  but  at  the  lumbo 
sacral  juncture,  and  especially  over  the  lumbo 
sacral  transverse  regions.  The  referred  pain 
will  be  along  the  anterior  cural  nerve  or  the 
distribution  of  the  nerves  coming  from  the 
lumbo-sacral  cord,  that  naturally  being  the 
nerve  most  commonly  irritated  as  it  passes  un- 
der the  transvei*se  processes  of  the  fifth  lumbar 
vertebra. 

With  this  type  of  anatomy  the  sternum  is  al- 
ways carried  high  so  that  the  chest  is  more 
rounded  than  in  tlie  normal  human  type  and  the 
diaphragm  is  held  high,  largely  because  of  the 
bulky  viscera  which  occupy  the  upper  part  of 
the  abdomen.  As  years  go  on  the  heavy  organs 
naturally  lead  to  stretching  of  the  abdominal 
wall  so  that  the  viscera  occupy  a  lower  level 
than  is  normal,  but  the  degree  of  sag  in  this 
type  is  markedly  less  than  is  seen  in  the  slender 
type  with  the  loosely  attached  viscera.  It  should 
be  remembered,  however,  that  the  degree  of  dis- 
placement is  not  that  which  determines  the  se- 
verity of  the  symptoms,  and  that  at  times  the 
sag  of  an  inch  of  an  organ  may  produce  more 
serious  difficulty  than  the  sag  of  several  inches. 

As  the  organs  sag  downward,  the  ribs,  while 
lowered  somewhat,  are  naturally  flared  at  the 
bottom  because  of  the  high  attachment  of  the 
organs  and  the  fact  that  the  amount  of  down- 
ward displacement  that  is  possible  with  them  is 
relatively  slight.  The  antero-posterior  diameter 
of  the  upper  abdomen  in  this  type  is  relatively 
but  little  changed  by  the  drooped  position  over 
that  which  would  exist  when  the  body  is  fully 
erect.  On  the  other  hand,  in  the  slender  type 
the  antero-posterior  diameter  of  the  upper  ab- 
domen is  much  less  when  the  body  is  drooped 

45 


than  when  fully  erect.  The  costal  border  in  this 
heavy  type  of  anatomy  is  always  broad  and 
usually  is  more  than  90°  rather  than  less. 

With  the  heavy  type  the  positions  assumed 
when  sitting  are  as  a  rule  much  less  serious 
than  with  the  slender  type,  since  the  structure 
of  the  body  as  a  whole  makes  the  droop  much 
less  marked,  and  since  in  the  sitting  position 
the  lower  abdomen  is  partly  supported  on  the 
upper  thigh  and  the  downward  drag  of  the  or- 
gans thereby  somewhat  lessened. 

The  position  at  night  is  naturally  of  import- 
ance, and  with  this  type  the  position  upon  the 
face  w^ould  cause  so  much  backward  pi'essure 
upon  the  viscera  and  structures  at  the  back  of 
the  abdomen  that  probably  harm  would  result. 
The  back  or  the  side  position  is  naturally  the 
best.  Since  the  lumbo  sacral  region  is  the  part 
most  commonly  strained  in  this  type  of  anatomy, 
the  back  ache  in  this  type  or  the  referred  leg 
pains  are  usually  relieved  by  recumbency,  the 
reverse  of  this  being  true  with  the  slender  type, 
in  which  with  the  sacral  strain  the  day  time  is: 
the  time  of  greatest  ease,  the  night  being  the 
time  of  greatest  discomfort. 

Deductio7is. 

If  that  which  is  here  stated  is  correct,  and 
verification  of  the  statements  should  not  be  diffi- 
cult, it  means,  in  the  first  place,  that  the  teach- 
ing and  study  of  anatomy  should  have  to  do  not 
only  Avith  the  normal  type,  but  that  the  other 
types  should  be  given  similar  recognition.  The 
need  of  this  broader  anatomic  training  must  be 
obvious  when  one  appreciates  how  rarely  the 
physician  is  consulted  by  the  person  having  the 
anatomy  as  it  is  commonly  taught. 

46 ' 


It  means,  also,  that  in  the  study  of  physiology 
the  elements  which  are  peculiar  to  each  type 
should  be  investigated  and  appreciated.  When 
the  elements  which  are  easy  of  study,  such  as 
the  gastric  secretions,  the  blood  pressure,  pulse 
rate,  temperature,  etc.,  vary  so  markedly  with 
the  different  types  there  must  be  similar  an9 
perhaps  more  important  variations  in  the  other 
features  which  are  part  of  our  physiology.  To 
study  all  individuals  from  the  same  point  of 
view  must  lead  to  much  confusion  and  explains 
in  part  the  different  reports  which  are  made  of 
seemingly  similar  investigation.  With  the  types 
so  widely  different  it  is  not  difficult  to  believe 
that  there  is  wide  variation  in  the  function  of 
the  different  parts.  The  physiology  as  a  whole 
should  be  studied  with  this  in  mind.  The  tem- 
perature, blood  pressure,  and  other  elements  of 
this  sort  should  be  observed,  but  also  the  prob- 
lems, such  as  the  mechanics  and  peristalsis  of 
the  stomach  and  bowel,  with  the  time  involved 
in  the  passage  of  food  from  one  part  to  the 
other.  These  must  vary,  and  each  type  should 
be  studied  by  itself,  since  it  is  obvious  that  study 
of  one  type  would  be  of  very  little  assistance  in 
interpreting  the  symptoms  or  functions  of  an- 
other. This  must  be  particularly  true  of  the 
chemical  observations  and  it  must  be  obvious 
that  in  beings  having  so  much  the  makeup  of 
creatures  so  widely  different  as  the  carnivora 
and  the  herbivora  there  is  probably  enough  of 
difference  in  the  body  metabolism  as  to  make 
such  studies  of  uncertain  value  unless  the  ana- 
tomic type  of  the  creature  studied  is  stated. 

It  means  that  probably  in  this  difference  in 
types  is  to  be  found  the  explanation  of  the  vary- 
ing effects  of  the  same  diet  upon  groups  of 
individuals.     That  one   becomes   fat   while   the 

47 


other  remains  thin,  or  that  one  suffers  distress 
while  the  other  thrives  upon  the  same  food  must 
be  due  to  something  other  than  the  food.  The 
fact  with  which  even  the  laity  is  familiar,  that 
meat  in  gout  is  harmful  becomes  a  matter  of 
interest  when  it  is  realized  that  the  herbivorous 
type  is  the  one  that  is  subject  to  gout.  Also 
the  fact  that  a  few  years  ago  so  many  of  the 
nervous  invalids  were  helped  by  the  diet  of 
chopped  red  meat  and  hot  water  of  Dr.  Salis- 
bury becomes  interesting,  since  this  type  of  pa- 
tient is  almost  always  of  the  carnivorous  type. 
It  apparently  means  that  while  all  human  be- 
ings have  elements  within  them  which  make 
possible  the  digestion  of  the  different  kinds  of 
food,  some  are  digested  with  greater  ease  than 
others,  and  that  this  fact  at  times  is  of  the 
greatest  importance  in  the  interpretation  of 
symptoms  and  their  treatment. 

It  means  in  the  medical  and  surgical  treat- 
ment of  our  patients  that  the  symptoms  should 
be  interpreted  in  relation  to  that  which  is  nor- 
mal for  the  special  type  of  anatomy  represented 
in  our  patient,  and  that  the  mechanical  condi- 
tions present  in  such  a  type  should  be  carefully 
studied.  A  blood  pressure,  for  instance,  that 
would  be  normal  for  one  type  might  be  danger- 
ously high  or  dangerously  low  for  the  other  type. 
A  disturbance  of  circulation  in  the  legs,  the 
varicose  veins,  or  in  the  lower  abdominal  struc- 
tures, varicocele,  etc.,  should  be  thought  of  not 
as  a  local  condition,  but  investigation  at  once 
started  to  see  what  is  pressing  upon  or  interfer- 
ing with  the  veins  above.  Correction  of  sagging 
organs,  or  the  removal  of  some  pelvic  tumor  may 
wholly  relieve  the  mechanical  interference  with 
the  veins  with  entire  relief  to  the  conditions  be- 
low.    The  treatment  of  the  vein  itself,  since  it 

48 


is  treating  a  symptom  only,  must  necessarily  be 
unsatisfactory. 

In  thoracic  conditions,  it  means  that  not  only 
should  the  disease  of  the  organ  itself  be  con- 
sidered, but  the  conditions  under  which  the 
special  organ  works  be  also  considered.  In  the 
slender  type,  since  the  chest  is  used  at  full  ex- 
piration and  since  the  movements  of  the  dia- 
phragm are  also  restricted,  the  lungs  should  not 
be  expected  to  become  strong  or  to  work  rightly 
until  the  conditions  upon  which  the  proper  ac- 
tion of  the  lungs  depends  are  made  possible. 
With  the  tuberculous  patient,  which  almost  al- 
ways is  of  this  type,  it  should  be  made  a  part 
of  our  work  to  see  that  the  body  is  so  used  and 
supported  that  the  chest  is  raised,  and  the  drag 
upon  the  diaphragm  removed,  so  that  the  nor- 
mal rhythm  of  respiration  is  possi])le,  as  much  as 
to  see  that  the  patient  is  given  fresh  air.  The 
air  cannot  get  into  the  lungs  unless  these  me- 
chanical elements  are  recognized.  The  same  is 
true  of  the  heart  action,  if  the  chest  is  low,  and 
the  diaphragm  depressed  so  that  the  suspensory 
ligament,  which  is  the  pericardium,  is  stretched. 
Not  only  must  the  heart  labor  at  a  disadvantage 
from  its  immediate  enviroment,  but  the  inter- 
ference with  the  diaphragmatic  action  must  be 
of  much  importance,  and  for  only  one  illustra- 
tion, the  unloading  of  the  abdominal  veins, 
which  is  dependent  so  much  upon  the  movement 
of  the  diaphragm,  must  be  disturbed.  When  the 
mechanics  of  the  heart  action  is  considered  one 
is  not  surprised  to  find  such  work  as  the  article 
by  M.  Herz^"  upon  ' '  Interference  with  the  Heart 
Action  by  Stooping,"  reported. 

In  the  abdominal  conditions  it  means  that 
they  should  be  given  proper  anatomic  and 
mechanistic  consideration.     It  may  be  that  the 

49 


individual  is  simply  receiving  food  that  is  de- 
signed for  an  entirely  different  type,  or  it  may 
be  that  the  organ  or  organs  are  so  mechanically 
out  of  adjustment  that  the  normal  function  is 
impossible.  The  imperfect  action  of  the  liver 
or  the  formation  of  gall  stones  may  be  due  to 
mechanical  interference  Avith  the  structures  upon 
which  the  function  depends.  The  fact  that  gall 
stones  are  found  so  commonly  in  the  heavy  type, 
while  the  cystic  bladder  is  seen  so  commonly  in 
the  slender  type,  probably  means  something 
which  has  both  a  physiologic  and  a  mechanistic 
significance.  The  inability  of  the  stomach  to 
empty  itself,  or  the  variations  in  the  character 
of  its  secretions,  may  be  due  to  the  position  of 
the  organ  itself  or  to  interference  with  the  ves- 
sels or  nerves  supplying  it.  The  function  of  the 
bowel,  both  large  and  small,  may  be  good  or  ill 
in  proportion  as  its  structure  is  normal  or  its 
position  is  correct.  Kinks  may  occur,  but  it 
should  be  remembered  that  while  some  are  seri- 
ous and  require  surgical  interference,  that  many 
times  if  the  mechanistic  features  are  appre- 
ciated, that  the  kink  can  easily  be  released,  while 
if  surgery  is  employed,  the  special  kink  may  be 
removed  but  the  structural  formation  is  such 
that  other  kinks  are  possible,  with  a  greater 
probability  of  their  developing  because  of  the 
post-operative  adhesions  which  are  sure  to  be 
added  to  the  structural  peculiarities.  The  ulcers 
of  the  stomach  or  duodenum  may  be  due  to 
improper  pressure,  as  has  been  fully  described 
by  Codman.^^ 

It  means  in  the  part  of  the  study  in  which 
the  x-ray  is  used,  that  the  difference  in  the  po- 
sition of  the  viscera  that  should  be  present  when 
the  body  is  recumbent  upon  the  side  or  back,  as 

50 


well  as  that  which  should  exist  when  the  body 
is  erect,  should  be  fully  understood. 

It  means  that  with  the  disturbances  of  the 
kidneys,  that  those  which  are  mobile  should  be 
expected  as  a  part  of  the  anatomy  of  the  slender 
type,  and  that  attempted  suture  of  such  organs 
can  hardly  be  successful  unless  there  is  much 
postural  training,  since  all  of  the  mechanics 
tend  to  redisplace  them.  In  the  so-called  dis- 
eases of  the  kidneys  it  should  be  remembered 
that  albumen  and  the  other  abnormal  elements 
are  only  symptoms  of  a  condition,  and  may  be 
due  to  improper  demand  put  upon  them  by  the 
wrong  food,  or  may  be  due  to  some  purely 
mechanical  condition.  When  the  anatomic  fea- 
tures are  considered  as  well  as  all  the  mechanis- 
tic features,  one  is  not  surprised  to  find  such 
work  as  Scholder  and  Weith^-  carried  on  at 
Lausanne,  showing  that  in  1254  school  children, 
in  over  20%  they  were  able  to  obtain  albuminu- 
ria by  putting  the  children  in  certain  definite 
postures.  Similar  work  by  Fisehl  and  E.  Pop- 
per^^  upon  albuminuria  is  of  additional  sugges- 
tiveness. 

With  the  presence  of  sugar  in  the  urine  it  is 
not  impossible  that  as  well  as  improper  food 
the  pressure  of  the  mobile,  heavy  organs  upon 
the  pancreas,  or  its  blood  vessels,  may  be  dis- 
tinctly causative  of  the  symptom.  Certain  it 
is  that  when  one  has  seen  cases  in  which  after 
most  careful  dieting  the  sugar  has  persisted  and 
then  after  supporting  tlie  organs  properly  the 
sugar  has  wholly  disappeared,  it  is  hard  to  be- 
lieve that  the  mechanistic  elements  are  not  of 
some  importance.  It  should  be  remembered  that 
the  diabetic  is  almost  always  the  heavy  type 
and  that  sugar  is  rarely  present  in  the  slender 
type,  except  occasionally  in  childhood,  and  then 

61 


only  in  an  evanescent  manner.  In  this  heavy 
type  the  organs  are  heavy  and  are  placed  in  the 
upper  abdomen,  while  in  the  slender  type  they 
are  much  lower.  One  cannot  help  wondering 
if  the  heavy  organs,  by  sagging,  may  not  crowd 
the  pancreas  or  the  sympathetic  ganglia  of  that 
region  with  etiological  importance.  The  sup- 
ports or  postures  which  are  used  should  be 
planned  with  reference  to  this. 

It  means,  in  considering  the  blood  diseases, 
especially  the  profound  anemias,  which  cannot 
be  explained  in  other  ways,  that  the  position  of 
the  spleen  or  the  effect  which  other  organs  may 
have  upon  its  function  should  be  considered. 
The  ease  with  which  the  blood  supply  of  this 
organ  could  be  shut  off  or  interfered  with  as 
the  other  organs  move  about,  must  be  apparent, 
while  the  possibility  of  the  spleen  itself  being 
displaced  or  its  vessels  twisted,  must  be  equally 
evident  as  we  come  more  and  more  to  under- 
stand the  mobility  of  the  various  viscera.  The 
fact  that  the  blood  recovery  has  taken  place 
rapidly  after  mechanical  treatment  has  been 
applied,  after  the  previous  continuance  of  the 
symptoms,  in  spite  of  the  ordinary  medical 
measures,  makes  it  seem  probable  that  to  make 
it  possible  for  the  organ  to  work,  is  perhaps  as 
important  a  part  of  treatment  as  any  other. 

It  means  that  with  the  disturbances  of  the 
other  abdominal  organs  that  both  the  anatomic 
and  the  mechanistic  features  should  be  consid- 
ered; that  the  stomach  and  liver  cannot  work' 
rightly  if  the  ribs  are  contracted  and  narrowed" 
so  that  there  is  practically  no  subdiaphragmatic 
space ;  that  the  pelvic  organs  cannot  work  right- 
ly and  must  be  congested  if  the  loose  abdominal 
organs  are  crowded  into  the  lower  abdomen  and 
pelvis. 


52 


It  means  that  in  studying  the  mental  diseases 
or  the  nervous  disorders,  since  with  the  former 
the  acute  conditions  are  usually  seen  in  the 
slender  or  carnivorous  type,  while  the  chronic 
or  degenerative  conditions  are  usually  seen  in 
the  heavy  type,  in  which  the  arteriosclerotic 
changes  are  common,  and  since  also  the  func- 
tional nervous  conditions  are  usually  seen  in 
the  slender  type,  that  probably  the  anatomic 
form  is  of  distinct  importance  in  the  under- 
standing of  such  conditions.  It  is  not  improb- 
able that  the  acquired  characteristics,  with  the 
mechanical  disturbance  of  the  physiology  which 
is  to  be  expected  under  such  conditions,  may  be 
of  distinct  etiological  importance. 

With  epilepsy,  the  recent  literature  so  strong- 
ly suggests  that  many  of  the  cases  are  due  to 
gastro-intestinal  derangements  that  it  is  not  un- 
reasonable to  wonder  if,  by  studying  the  ana- 
tomic condition  fully,  we  may  not  find  sugges- 
tions that  will  be  helpful  in  our  treatment. 
From  the  mechanistic  point  of  view,  when  oc- 
casionally one  sees  the  convulsions  stop  instantly 
by  the  mere  change  of  position  to  that  in  which 
there  would  be  less  pressure  of  the  viscera  upon 
the  ganglia  and  vessels  in  the  posterior  part  of 
the  upper  abdomen,  it  makes  one  question  if 
these  mechanistic  elements  are  not  part  of  the 
complex  condition  that  shows  itself  in  the  con- 
vulsion. 

It  means  that  in  studying  the  disturbances 
of  the  internal  glands  that  since  the  hyper-thy- 
roid conditions  are  usually  seen  in  the  slender 
type,  while  the  hypo-thyroid  conditions  so  com- 
monly occur  in  the  heavy  type,  it  is  possible 
that  in  the  better  understanding  of  the  physi- 
ology of  the  whole  body  with  such  an  anatomic 

5a 


basis,  our  treatment  of  these  conditions  may  be 
more  satisfactory. 

It  means  that  in  studying  such  local  condi- 
tions as  the  disturbances  of  the  eye,  it  should  be 
appreciated  that  the  circulation  in  the  eye  may 
be  so  materially  changed  by  postures  which 
interfere  with  the  blood  flow  to  the  head  that 
the  shape  of  the  eye  is  changed,  the  near  sighted 
eye  resulting  (Howe^*).  In  such  diseases  as 
cataract,  since  these  commonly  develop  in  the 
heavy  or  herbivorous  type,  as  is  true  of  the 
hypertrophic  arthritis,  perhaps  there  is  some- 
thing else  to  be  done  other  than  wait  for  suit- 
able time  for  operation.  With  such  understand- 
ing of  the  anatomic  types  and  their  physiologic 
potentials,  one  is  encouraged  in  such  hope  by 
work  such  as  is  reported  by  Connor.^^ 

With  some  of  the  other  inflammatory  con- 
ditions of  the  eye  it  is  not  improbable  that  the 
function  of  the  ophthalmologist  will  extend 
much  farther  than  the  application  of  the  local 
remedies,  but  that  a  kink  in  the  bowel  leading 
to  an  eye  infection  or  the  interference  with  the 
circulation  in  the  eye  as  a  result  of  some  local 
mechanical  feature  may  be  the  real  cause  of  the 
trouble  and  that  his  greatest  function  is  seeing 
that  these  conditions  are  corrected. 

It  means,  in  obstetrical  work,  that  the  differ- 
ent types  have  very  different  potentials.  The 
slender  type  of  woman  is,  as  a  rule,  in  better 
health  than  usual  during  pregnancy,  after  pass- 
ing the  first  month  or  two,  undoubtedly  in  part 
due  to  the  support  which  the  abdominal  organs 
receive  from  the  enlarging  uterus.  The  labor 
also  is  usually  easy  with  this  type,  as  one  would 
expect  from  the  small  amount  of  pelvic  fat,  the 
slender  or  small  fibred  pelvic  muscles,  and  the 
slender  pelvis  with  the  loose  pelvic  joints.     In 

54 


the  last  month  of  pregnancy  the  sacral  pain  with 
frequent  sciatica  is  easily  understood  by  the 
form  of  the  pelvic  joints,  and  the  quick  relief 
from  the  pelvic  joint  strapping  is  not  surpris- 
ing. The  possibility  of  increasing  the  diameters 
of  the  pelvis  in  this  type  and  thereby  assisting 
at  the  time  of  labor,  by  simply  manipulating  the 
sacrum  should  be  realized,  as  well  as  the  greater 
need  of  pelvic  support,  by  swathe  or  strapping 
while  the  involution  is  going  on.  Also  with  this 
type,  to  maintain  the  higher  position  of  the  ab- 
dominal organs,  the  upright  position  should  not 
be  assumed  until  the  abdominal  wall  has  re- 
gained its  proper  tone  and  suitable  corsets,  to 
give  low  abdominal  support,  are  fitted.  It 
should  be  appreciated  that  conception  with  this 
type  occurs  easily  and  large  families  are  com- 
mon. With  the  heavy  type  childbearing  is  a 
more  difficult  matter,  conception  occurs  less  fre- 
quently, and  the  pregnancy  is  usually  a  time  of 
much  discomfort,  with  distressing  back  ache  due 
partly  to  the  relaxing  of  the  broadly  formed 
sacro-iliac  joints  and  partly  to  the  strain  of 
the  broadly  formed  lumbo-sacral  joint,  due  to 
the  changing  poise.  The  labor  is  usually  diffi- 
cult, partly  because  of  the  general  lack  of  flexi- 
bility of  the  pelvic  girdle  and  the  low  back.  It 
is  with  this  type  that  back  ache  with  referred 
leg  pains  often  last  for  long  after  confinement 
because  of  the  chronic  joint  strain. 

With  the  normal  human  type  the  obstetrical 
condition  is  midway  between  these  two  types. 
It  is  neither  as  easy  as  with  the  slender  nor  as 
hard  as  with  the  heavy  type. 

It  means  that  with  the  orthopedic  conditions 
not  only  should  the  special  joint  or  part  be 
protected,  but  the  type  of  the  being  as  a  whole 
should  be  studied  and  the  function  of  the  dif- 

55 


fereut  parts  assisted  as  much  as  possible.  In 
the  fitting  of  apparatus  this  is  particularly  im- 
portant, and  anything  that  interferes  materially 
with  the  visceral  function  or  with  the  proper 
development  of  the  body  as  a  whole  should  be 
most  carefully  avoided.  This  should  be  espe- 
cially considered  in  some  of  the  newer  methods 
for  the  treatment  of  lateral  curvature. 

It  means  that,  in  the  treatment  of  the  common 
weak  foot  conditions,  cure  can  hardly  be  ex- 
pected unless  the  elements  of  faulty  mechanics 
which  have  led  to  the  foot  strain  are  corrected. 
Of  these,  among  the  seemingly  remote  causes 
of  strain,  it  should  be  remembered  that  the  ab- 
normal drag  of  the  abdominal  viscera  will  neces- 
sarily throw  the  body  out  of  poise,  so  that  the 
balance  of  the  feet  will  be  disturbed.  It  means 
that  in  the  treatment  of  the  common  strains  of 
the  sacro-iliac  joints  that  cure  is  not  to  be  ex- 
pected unless  the  abnormal  forward  inclination 
of  the  pelvis  which  has  led  to  these  strains  is 
overcome.  It  means  that  in  the  treatment  of 
the  chronic  joint  diseases  that  the  treatment  of 
the  local  condition  is  only  part  of  the  problem. 
The  joint  symptoms  are  usually  due  to  some 
systemic  disturbance.  To  find  the  primal  cause 
of  the  difficulty  and  see  that  it  is  corrected 
is  naturally  the  most  important  function  of  the 
orthopedist. 

It  means,  and  this  is  apparently  the  most 
sobering  phase  of  the  subject,  that  as  the  result 
of  the  splendid  work  of  our  profession  in  pre- 
ventive medicine,  the  slender  type,  which  for- 
merly because  of  its  low  resistance  added  so 
much  to  the  mortality  of  infancy  and  childhood, 
is  now  being  saved.  It  means  also  that  with 
this  type  growth  without  proper  guidance  in- 
evitably produces  a  still  weaker  physique,  with 

56 


drooped  figure,  narrow  chest,  etc.,  etc.  These 
acquired  characteristics  added  to  the  congenital 
form  accentuate  the  congenital  elements  to  such 
an  extent  that  they  are  much  more  sure  of  being 
present  in  the  following  generation,  and  it  be- 
comes a  mere  matter  of  biology  to  see  that  such 
elements  which  represent  physical  instability 
will  become  more  and  more  marked  in  the  sub- 
sequent generations.  This  together  with  the 
fact  that  the  slender  type  is  the  most  prolific, 
makes  evident  that  the  stock  from  which  the  race 
is  recruited  will  become  steadily  less  strong. 
That  this  is  actually  taking  place,  one  has  only 
to  study  any  considerable  group  of  school  chil- 
dren of  the  present  time  to  see  how  commonly 
the  slender  type  is  found.  That  this  was  not 
formerly  the  case  is  suggested,  at  least,  by  the 
study  of  the  engravings  of  groups  of  individuals, 
such  as  were  so  commonly  made  from  50  to  100 
years  ago,  in  which  the  broad  or  round  faced 
type  is  almost  the  only  one  shown.  This  is,  of 
course,  equally  true  at  the  present  time  in  those 
countries  in  which  modern  medicine  has  exerted 
but  little  influence,  and  consequently  the  infant 
or  child  mortality  is  extremely  high.  The  simi- 
larity in  the  form  of  the  Oriental  is  apparently 
to  be  explained  largely  by  this,  as  is  true  also 
of  the  form  of  the  pure  African.  The  slender 
type  is  not  often  seen  among  these  races. 

Since  with  the  work  of  our  profession  and 
the  general  development  of  our  civilization,  the 
structure  of  the  human  family  is  being  modified, 
it  certainly  behooves  us  to  see  that  the  modifica- 
tion is  beneficial  and  not  harmful.  For  this 
reason  the  great  opportunity  for  our  profession 
consists  in  not  only  saving  the  lives  of  those 
who  are  physically  delicate,  but  in  seeing  that 

57 


they  are  developed  into  stronger  and  more 
healthy  individuals. 

Similarly  this  is  the  great  opportunity  and 
responsibility  for  the  educator.  The  slender 
child,  if  guided  and  trained  rightly,  becomes  the 
agile,  quick  moving,  quick  thinking  type  of  in- 
dividual. To  obtain  such  a  development  means 
most  constant  perseverance  with  the  education 
and  training  of  such  a  child,  and  this  training 
should  begin  in  the  lowest  grades  of  our  school 
system,  insistance  being  put  always  upon  poise 
with  its  resulting  efficiency.  If  the  proper  ex- 
ercises are  started  in  the  lower  grades  and  are 
increased  in  vigor  and  complexity  as  the  child 
progresses,  the  children  can  be  brought  up  to 
adult  life  with  very  different  physique  from 
that  which  is  so  commonly  seen  at  the  present 
day.  One  of  the  most  serious  phases  of  the  edu- 
cational aspect  of  the  problem  is  that  since  this 
slender  type  is  sensitively  and  nervously  organ- 
ized, with  distinct  nervous  instability,  intellec- 
tual training  must  necessarily  increase  this  in- 
stability, unless  with  the  intellectual  training 
the  training  of  the  body  is  insisted  upon  so  that' 
the  proper  physical  support  is  given  for  the 
mental  development.  If  education  is  approached 
in  this  manner  it  is  a  blessing,  but  if  the  intel- 
lectual aspect  alone  is  held  it  must,  in  so  far 
as  this  slender  type  is  concerned,  be  harmful 
both  to  the  individual  and  to  the  race. 

One  would  certainly  be  a  pessimist  of  the 
most  profound  type  if  he  felt  that  tlie  splendid 
work  of  our  profession  along  preventive  medical 
lines  was  a  curse  to  the  race  by  preserving  the 
lives  of  the  slender  or  delicate  physical  type, 
which  Nature,  in  keeping  with  the  law  of  the 
survival  of  the  fittest,  would  have  thrown  off, 
or  that  the  splendid  work  of  the  school  and  col- 

5S 


lege  is  also  harmful  to  the  race  by  accentuating 
qualities  of  weakness ;  but  such  must  be  the  fact, 
unless  something  else  is  added  to  the  mere  sav- 
ing of  the  lives  and  to  the  common  system  of 
education  as  it  exists  today.  If  the  physician 
and  the  teacher  recognize  these  facts  and  apply 
the  natural  principles  for  the  proper  develop- 
ment of  these  individuals,  the  result  must  be 
inevitable — a  stronger  and  finer  race. 

What  higher  incentive  can  there  be  for  work 
that  that  which  benefits  the  individual  and  at 
the  same  time  by  helping  him  gradually  re- 
moves the  weaker  elements,  which  if  perpetu- 
ated would  surely  lower  the  vitality  of  the  race 
as  a  whole  ?  The  free  will  of  choice  with  which 
man  is  endowed  and  upon  which  his  moral  de- 
velopment depends  seems  to  find  a  similar  re- 
sponsibility in  the  development  of  a  better  and 
Isetter  creature  along  physical  lines,  and  this 
development,  as  is  true  with  the  other,  follows 
simple  and  understood  laws.  What  greater  in- 
centive for  one's  best  endeavor  could  a  man  de- 
sire than  to  become  conscious  of  the  greatness 
of  this  opportunity?  In  the  moral  choice  man 
is  given  great  responsibility  and  in  the  physical 
the  responsibility  is  none  the  less  great,  unless 
the  development  of  the  human  family  is  to  be 
governed  by  the  same  law  of  survival  of  the  fit- 
test and  natural  selection  which  has  governed 
the  development  of  the  lower  forms  of  life.  That 
man  has  for  his  future  something  better  than 
these  laws  would  make  possible,  everyone  must 
feel  who  has  thouglit  at  all  beyond  the  needs  of 
the  day,  and  in  the  hope  of  stimulating  thought 
and  activities  along  these  lines  this  contribu- 
tion is  presented. 


59 


••• 


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'*  Oodman,  E.  k. :  Chronic  Obstruction  of  the  Duodenum  by 
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"  Scholder  and  Weith:  Archiv  fiir  Orthopiidie,  Mechano therapie 
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'■'Howe:  Transactions  of  the  Fourth  International  Congress  on 
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